docnikki
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A 69-year-old man with a prolonged history of hypertension and diabetes mellitus is brought to the emergency department by his daughter with right lower extremity weakness and slurred speech. These symptoms developed suddenly over the last two hours. One month ago, he underwent laparoscopic cholecystectomy. He had a severe hematuria six weeks ago. Upon arrival, his blood pressure is 160/90 mm Hg, and his heart rate is 72/min. Neurological examination reveals right lower extremity weakness with 3/5 motor strength and decreased sensation in the same leg. Neck examination reveals a mild carotid bruit on the left. The EKG shows normal sinus rhythm. A CT scan of the head is normal. All laboratory tests are normal. Which of the following is most appropriate at this time?
(A) Aspirin 325 mg daily
(B) Aspirin 325 daily and dipyridamole 200 mg twice a day
(C) Coumadin
(D) tPA intravenously
(E) Heparin intravenously
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| farnsworth
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A?
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| dr.wad
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( D )..... ( i guess this is ticky one )
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| dr.wad
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........................
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| farnsworth
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D is contraindicated (uncontrolled hypertension and previous surgery)
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| Korotkoff
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A
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| doc_clotaire
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(A) Aspirin 325 mg daily
___________________
The elevator to succes is broke ,you must take the stairs
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| docnikki
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I had chosen A too!!! but thats not right.  Its D. tpa.
This patient is evaluated within three hours after the onset of his neurological deficit, and he should receive tPA. It is the only approved medication for the treatment of acute ischemic stroke. It is effective in reducing neurological deficits in selected patients without CT-scan evidence of intracranial hemorrhage when administered within three hours of the onset of symptoms. Administration of tPA after three hours has not been proven to be effective or safe. A laparoscopic cholecystectomy a month ago and hematuria alone are not contraindications to the use of tPA. They are relatively minor risks for an increased risk of bleeding. Although the blood pressure is elevated in this case, it is still <185/110 mm Hg. Contraindications to the use of thrombolytics are a recent hemorrhage, an increased risk of hemorrhage, a recent myocardial infarction, an arterial puncture at a noncompressible site within the preceding seven days, major surgery within fourteen days, a systolic blood pressure above 185 mm Hg, or a diastolic pressure above 110 mm Hg. Gastrointestinal or severe urinary tract hemorrhage is also a contraindication to thrombolytic therapy. Heparin has no role in the management of patients with completed stroke, except when there is a cardiac source of embolization, such as a thrombus or atrial fibrillation. Treatment is then started with heparin and warfarin. There is an increased risk of early and serious intracranial and extracranial bleeding, and no long-term neurological benefit with heparin treatment for patients with acute ischemic stroke
It says that "Gastrointestinal or severe urinary tract hemorrhage is also a contraindication to thrombolytic therapy",,but I think the hematuria was 6weeks ago and had it been within a month it would have been a contraindivation..anyone knows the right time period?
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| farnsworth
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good research
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