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 Initial Best Step & Next best step in Mx  



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Author15 Posts
  #1

Hi there. I am thinking to start this post where everyone can write abt say one condition/disease. I guess I will do that first. The more replies, the more we all wud be able to benefit from this chain.


Pulmonary Embolism

Sudden onset of SOB, pleuritic chest pain with clear lung sounds should always raise the suspicion of PE (3rd leading cause of death among hospitalized pts). Low grade fever and leukocytosis are common in embolic disease however persistent high grade fever and marked leuckocytosis suggest an infection such as pneumonia.

When suspecting Pulmonary Embolism.

Initial test is Chest xray to rule out pneumothorax, pneumonia, bronchitis, asthma, pleural effusion and myocarditis (in PE its mostly normal) and ABGs (most often show resp alkalosis with hypoxia and hypocarbia because the pt is usually hyperventilating and elevated A-a gradient).

If there is suspicion of PE on Chest Xray then we can also skip the ABG and directly do a Ventilation Perfusion Scan. If a classic pattern of mismatched perfusion defect (a large area of perfusion defect without ventilation defect) is observed, proceed with treatment. If scan is normal, you can rule out significant pulm thromboembolism.In a substantial number of pts, V/Q scan result is inconclusive so best next step wud be to do Venous U/S or CT Angiogram of Chest. Diagnosing DVT makes the probability of PE very high so proceed with treatment.

Gold standard test is pulmonary angiogram which is usually not done.

Patient with suspected PE shud be given supplemental oxygen and placed on bedrest to reduce oxygen consumption. Heparin anticoagulation started with a bolus of 5,000-10,000 units followed by constant infusin of 1000 units/hr to prolong PTT to 1.5-2.5 times normal.

Embolectomy is the intervention of choice is pts in which anicoagulation is contraindicated.

Inf Vena Caval Filter can be placed if there is recurrent thromboembolism inspite of adequate anticoagulation or in cases of high risk of DVT where we cannot anticoagulate the patient.





  #2

don't forget the EKG, should be initial step to r/o cardiac related problems of SOB, then CXR and ABG (as u mentioned suggest PE but not specific)
V/Q is next, unless Heparin is also an answer choice. If there are all the classical clues to PE and both are gievn then go with heparin, then do V/Q. If V/Q confrims the Dx of Pe great if not P/E then u can alwasy stop the heparin. The reason why is b/c mortality is high w/ P/E so better safe than sorry


  #3

In Addition
Embolectomy is preffered in Unstable Pts if CI to anticoag exists
n IVC Filter preffered in stable pts or stable but developing another PE while on anticoag


  #4

In addition
Spial CT prefferd over V/Q if there is associated Lung abnormalites


  #5

Thanx for ur additions doyoudig. Hope others will also start posting some diseases :-)


  #6

MULTIPLE SCLEROSIS

Best initial test (BIT)... MRI
Most accurate test (MAT).. MRI



  #7

CENTRAL VERTIGO

BIT .. MRI



  #8

Biliary colic BIT = biliary tract + gallbaldder US

Intracranial hematoma + displacement of midline structures NBS = emergency craniotomy

Spinal cord injury suspition NBS = corticosteroids

Typical hypertrophic pyloric stenosis NBS = treatment (no tests needed)



  #9

GUILLIAN BARRE SYND
BIT... LP
MAT..EMG
Best initial treatment is IVIG ( NEVER ANSWER prednisone because it is not effective)



  #10

Traumatic rupture of diaphragm suspition NBS = laparoscopy

Traumatic rupture of aorta suspition BIT = CXR, then spiral CT scan

Urethral injury suspitino BIT = retrograde urethrogram

Anterior urethral injury NBS = surgery

Posterior urethral injury NBS = suprapubic drainage + delayed repair

Bladder injury suspition BIT = retrograde cystogram with post void films

Renal injury suspition BIT = CT sacn

Testicle rupture suspition BIT = sonogram



  #11

Great thread---Here are my contributions---Will add more!

*NSIM in cirrhotic patient with Varices ---> VIT-K and NOT FFP...Though VIT-K administration does not correct coagulation abnormalities-It is still given.
FFP is given only when there is active bleeding

* Confirmatory diagnosis for CML : Cytogenetic analysis
CLL : Lymph node biopsy

*DUodenal ulcer---> NSIM is NOT ENDOSCOPY------It is done only when symptoms like vomiting,fever,weight loss is present..---Do H.pylori Serology


  #12

MYASTHENIA GRAVIS
BIT.. Acetyl choline receptor antibody test ( tensilon testing is only chosen when AChAb Test is not available on answer options because it is not specific for MG)
MAT.. EMG



  #13

Thyroid nodule BIT = TSH; if normal = fine needle biopsy

Neonate clavicle fracture NBS = reassurance (no treatment needed)

HIV patient with esophagitis symptoms NBS = treat with fluconazole

Ligamentous injury of knee suspition BIT and MAT = MRI

Ischemic colitis suspition BIT = CT scan; colonoscopy only if results are equivocal

Diffuse esophageal spasm suspition BIT and MAT = manometry







  #14

SEVERE HYPERCALCEMIA (Ca > 15mg/dl) ...NBS is IVF..N/S
ASYMPTOMATIC MILD HYPERCALC....NBS ... reduce calcium intake to 400mg/d and oral hydratiogn



Edited by tolito on Jun 30, 2007 - 6:57 PM

  #15

1. Pt with worsening Asthma & Eosinophils:

Prednisone ( Acute bronchopulmonary Aspergillosis)

2. Pt with worsening Asthma & sympt of GERD: (Clue--> Nocturnal exacerbations is the main issue)

BNS--> Life style modification & PPIs

3. Patient with 2 wks persistent pneumonia though properly treated with Abs:

1st step---> get a CT on chest to see any tumors, LNs, or an abcess blocking the bronchi

2nd step---> Bronchoschopy(flexible) to visualize, romove a mucus plug


4. Pt presents with massive hemoptasis ( > = 600ml/d)

BNS--> Rigid bronchoshope to identify bleeder & stop it ( Lazer cautary or another)





Edited by cirus on Jul 01, 2007 - 2:39 AM




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