smalley
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1)a 24 yr woman c/o not feeling well for past several days.h/o gen weakness,confusion ,fatigue.no h/o fever.nausea ,vomitting .abd pain. she drinks a lot of water,urinates every 1-2 hrs,also at night she gets up an goes once or twice
has a history of major depressio for which she always sees a doctor.examination shows she is well hydrated. temp 98.4 f bp 120/80 pulse an rr normal heart regular. grade 2/6 systolic murmur along left sternal border. which of the foll will be most compatible with her diagnosis
a hypernatremia and high urine sodium
b hyponatrremia and high urine sodium
c hypernatremia and low urine sodium
d hyponatremia and low urine sodium
e hypernatremia and normal urine sodium
2 which of the foll is useful in monitoring pt compliance in a man with h/o alcohol abuse who has enrolled himseld in alchol rehab program
a carbohydrate def transferrin
b gamma glutamyl transferase
c mcv
d serum triglycerides
e uric acid
3 a 78 yr old man is admitted to hosp b/c of acute onset of dysuria .freq ,profound malaise and shaking chills.temp 104f BP 105/62 pulse 120 and rr 28.profound tenderness i rt costovertebral angle. urinalysis shows rbc 10/hpf, wbc 100/hpf,protein 2+,cats none.a urine sample is sent for culture.pending results which is the most appropiate next step in mgt
a single dose cephalexin
b single dose tmp sx
c infusion of ringer lactate
d im ceftriaxone an oral doxycycline
e iv ampicillin and gentamicin
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| smalley
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pls exp ur answers
thanks
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| dr.wad
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D- hyponatremia and low urine sodium. ( psychogenic polydepsia ??? )
B-gamma glutamyl transferase
E - IV ampicillin and gentamicin ( acute pyelonephritis )
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| smalley
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still not rt
cmmon frens
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| mildus
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1.It sounds to me like diabetes insipidus, It is true that she has major depression, but it is not so easy to state that she has psychogenic polydipsia, since she wakes up at night in order to drink water (this would not occur in psychogenic polydipsia!), so it sounds more like diabetes insipidus. What do others think?
2. I think it is A, CDT is the most efficient marker for alcohol relapses, followed by GGT.
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| mildus
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1. oh, I have just seen that it doesn't say that she wakes up to drink but to urinate, so psychogenic can't be excluded
Edited by mildus on 01/28/08 - 02:49 PM
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| farnsworth
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c
a (most sensitive and specific biomarkers are CDT or the combination of CDT and gGT).
c? (patient is probably in septic shock, first fluid resuscitation followed by ABx therapy)
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| Ivonne
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Ok regarding question number 2 i did a little research and found this:
So 2---------->A
A newer test takes advantage of an aberrant form of transferrin that is elevated in individuals with heavy alcohol use. The assay measures carbohydrate-deficient transferrin (CDT). CDT has been proposed to be a more sensitive and specific indicator of heavy drinking.[23] This is important in clinical settings because patients may minimize their reported level of alcohol consumption during history-taking.[24] The diagnostic specificity of CDT for recent heavy drinking has been reported to be 70.0% in patients with non-alcohol-induced liver cirrhosis, 88.2% in hepatitis patients, and 93.5% in patients with nonspecific increases in GGT.[25] CDT is less affected by nonalcoholic liver disease, and there is evidence that CDT is less sensitive for the detection of heavy drinking in women.[26]
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| Ivonne
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ok a little bit more awake now
1.-It is hard to diagnose without labs such as serum and urine osmolarity but since She has h/o major depression and normotension maybe she has psychogenic polydipsia which will show normovolemic hyponatremia and low urine sodium---------->D but there is no way to rule out diabetes insipidus without labs and water restriction test...even new onset diabetes mellitus can fit in the differential...
2.-A for sure
3.-Patient needs antibiotics and hydration-------->E or C
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| farnsworth
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3) C - rationale: the patient meets sepsis criteria, so it is important to start fluid therapy (patient has probably urosepsis and should be considered unstable) to keep him from crashing, followed by administration of antibiotics.
The sepsis guidelines have just been updated!
http://www.ccmjournal.com/pt/re/ccm/abstract.0000...!327387095!181195628!8091!-1
One of the most remarkable article published in 2006 (in my opinion):
http://www.ccmjournal.com/pt/re/ccm/abstract.0000...!327387095!181195628!8091!-1
--> if ABx therapy is initiated in the first hour of sepsis-related hypotension, the survival rate is close to 80% and decreases by 7.6% for every hour the ABx therapy is delayed (in the following six hours). So (E) is a reasonable option, but not the most appropriate next step.
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| Ivonne
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Thanks for info farnsworth, makes sense hydrate first then antibiotics even to decrease renal damage by antibiotics.
Why do you think that the first one is C?
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| farnsworth
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Hi Ivonne,
I think the first one is C because I suspect the pt to have a diabetes insipidus (nocturia!) so I expect the pt to show up with hypernatremia and low urine sodium. But I have to admit that this is just an educated guess, because lab values helpful for diagnosis (glucose, Ca++) are missing, so you are right: diabetes mellitus and psychogenic polydipsia fit very well into the differential.
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| smalley
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1 d primary polydipsia leading to dil hyponatremia
2 cdt more sp than ggt for alchol compliace monitoring
3 e
regarding e i want to know why not put hydration first(choice c) since his bp is quite low acccording to abcde protocol?
thanks friends
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| lampard
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For me
1) D There is real diagnostic dilema over DI and psychogenic polydipsia. But the qustion clearly mentions the patient being well hydrated ( which I guess tilts th balance towards Psychogenic polydispsia)
Nevertheless I still feal they should have given serum Na conc. for a definitive Dx to be reached
2. CDT
3. It can't be acute pyelonephritis - No casts....
So it has to be a lower urinary tract infection. Treat with antibiotics
ampi - genta could be the best...
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| lampard
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For me
1) D There is real diagnostic dilema over DI and psychogenic polydipsia. But the qustion clearly mentions the patient being well hydrated ( which I guess tilts th balance towards Psychogenic polydispsia)
Nevertheless I still feal they should have given serum Na conc. for a definitive Dx to be reached
2. CDT
3. It can't be acute pyelonephritis - No casts....
So it has to be a lower urinary tract infection. Treat with antibiotics
ampi - genta could be the best...
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| lampard
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with a BP of over 90 mmHg systolic, the patient doesn't qualify for being called in sepsis / shock.
hence no need of aggressive hydration.
Treat the underlying disease first
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